A 54-year-old woman with a mechanical mitral valve replacement on warfarin is listed for elective laparoscopic cholecystectomy. Which perioperative anticoagulation plan is MOST appropriate?
- A Continue warfarin uninterrupted through the day of surgery
- B Stop warfarin 3 to 5 days before surgery and bridge with therapeutic-dose low molecular weight heparin ✓
- C Stop warfarin 24 hours before surgery with no bridging
- D Substitute aspirin for warfarin two weeks before surgery
Correct answer: B. Stop warfarin 3 to 5 days before surgery and bridge with therapeutic-dose low molecular weight heparin
Explanation
A mechanical mitral valve carries the highest thromboembolic risk among prosthetic valves, so guidelines recommend temporary interruption of warfarin 3 to 5 days preoperatively with bridging using therapeutic-dose LMWH or unfractionated heparin, resumed when surgical haemostasis is secure. Continuing warfarin risks serious surgical bleeding, while unbridged interruption risks valve thrombosis. Aspirin provides inadequate protection against mechanical valve thrombosis and is never an acceptable substitute.
Reference: Miller's Anesthesia, 9th ed.
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Written and medically reviewed by the StethoPrep medical team.